Hallux valgus: Patología tridimensional. Nuevo enfoque terapéutico

Introducción: el hallux valgus es la deformidad musculoesquelética más frecuente. La laxitud y la hipermovilidad tarso metatarsiana favorecen su desarrollo. El objetivo de este trabajo es plantear una patología tridimensional, y elaborar un algoritmo quirúrgico para cada patrón de deformidad, incorporando el componente rotacional del metatarsiano. Materiales y métodos: evaluamos prospectivamente una serie de 89 casos entre febrero de 2020 y febrero 2021, 80 mujeres y 9 hombres. Nivel de evidencia IV. La edad promedio fue 39 años y el seguimiento 11.3 meses. Utilizamos la clasificación de Hardy-Clapham y separamos 2 grupos, los hallux sin componente rotacional (tipo 1 a 3), y aquellos con componente rotacional (tipo 4 a 7). Resultados: el 59% entraron en el primer grupo, a los cuales se realizó osteotomía distal en chevron acorde a la deformidad en el plano frontal. El 41 % restante tuvo componente rotacional, y se realizó una osteotomía distal en chevron rotacional, crecientica en la base, o artrodesis de Lapidus modificada, según la deformidad en plano frontal o inestabilidad asociada. Consolidaron todos pacientes. AOFAS 94.5%, VAS 0.71 y 100% de satisfacción. Discusión: el componente rotacional es fundamental en la interpretación del hallux valgus, pero no es el único para tener en cuenta. El mismo puede no estar presente o no ser trascendente, y se alcanzan excelentes resultados como los publicados por décadas. Es fundamental diferenciar los pacientes con componente rotacional para realizar el tratamiento adecuado. Conclusión: considerando el hallux valgus una patología tridimensional, proponemos un protocolo de tratamiento acorde para cada paciente.

Pé torto congênito adulto inveterado na mielomeningocele e o método de Ponsetti como escolha: relato de caso

O método de Ponsetti é considerado, hoje, o padrão-ouro para o tratamento do pé torto congênito, inclusive em casos sindrômicos como a mielomeningocele. Sua indicação em casos negligenciados é bem estabelecida em crianças e adolescentes, mas para adultos, permanece incerto. Apresenta-se um caso clínico de uma paciente de 27 anos, portadora de mielomeningocele, com pés tortos congênitos negligenciados, que foi tratada nessa idade, pela primeira vez, com o método de Ponsetti, com obtenção de bons resultados. Em países em desenvolvimento, frequentemente encontram-se pacientes adultos portadores de pés tortos congênitos que não tiveram acesso a assistência a saúde. Apesar da idade limite para instituir o método de Ponsetti como opção terapêutica ainda ser obscura, é uma opção barata, segura, acessível, plausível de resultados satisfatórias mesmo em casos adultos, negligenciados e síndrômicos.

Pseudotumor hemofílico de tobillo - A propósito de un caso

Los Pseudotumores Hemofílicos, son lesiones de baja prevalencia, associadas a el déficit de factor de la coagulación XIII o IX, característicos de la Hemofilia. La localización es más frecuente en zonas como la cadera o el iliopsoas, mientras que en articulaciones distales son exóticos. Nosotros mostramos en este caso el desarrollo de un Pseudotumor Hemofílico en relación al abordaje anterolateral convencional de artroscopia de tobillo, en un paciente con Hemofilia tipo A leve, quien requierió manejo quirúrgico por artropatía hemofílica.

What is new about hallux rigidus?

Hallux rigidus (HR) represents one of the most frequent forefoot disorders, together with hallux valgus and lateral toe deformities, being the most frequent degenerative process in the foot and ankle.This publication is the result of the collaboration of colleagues of the Spanish Society of Medicine and Foot and Ankle Surgery (Sociedad Española de Medicina y Cirugía del Pie y Tobillo, SEMCPT) and the Argentinean Society of Medicine and Foot and Leg Surgery (Sociedad Argentina de Medicina y Cirugía de Pie y Pierna, SAMCPP). It is an honor for us to have this work edited in the Journal of the Foot & Ankle, a journal with a marked Latin identity. We really thank Alexandre Leme Godoy-Santos, Chairman of the Editorial Board, for his help and contribution. This update topic has been coordinated by R. Viladot Pericé and A. Viladot Voegeli, together with M. Herrera and M. Núñez-Samper.Considering the interest and the extent of this topic and, according to the coordinators, we have divided the publication into two parts. The first one describes general aspects (definition, etiology, classification, treatment algorithm, etc.) and the conservative treatment of HR, whereas the second one addresses the different surgical techniques described to treat this disease.The aim of this work is to review our knowledge on HR and to perform an update on the innovations that have emerged during the last years.

Hallux valgus measurements using weight-bearing computed tomography: what changes?

Objective: To assess whether traditional hallux valgus (HV) measurements obtained with conventional radiography (CR) correspond to those obtained with weight-bearing computed tomography (WBCT). Methods: In this retrospective case-control study, 26 HV feet and 20 control feet were analyzed with CR and WBCT. Hallux valgus angle (HVA), intermetatarsal angle (IMA), interphalangeal angle (IPA), distal metatarsal articular angle (DMAA), sesamoid station (SS), and first metatarsal head shape were measured. Chi-square tests were used to compare hallux valgus and control patients. T-tests were used to compare CR and WBCT. P-values less than 0.05 were considered significant. Results: WBCT was capable of discriminating patients with HV from controls, showing higher mean values for HV patients than controls in HVA (35.29 and 9.02, p < 0.001), IMA (16.01 and 10.01, p < 0.001), and DMAA (18.90 and 4.10, p < 0.001). When comparing the two methods, differences were not significant between CR and WBCT measurements in HVA (-0.84, p = 0.79), IMA (-0.93, p = 0.39), IPA (1.53, p = 0.09), or SS (p = 0.40), but were significant for DMAA (13.43, p < .0001). CR analysis yielded varied metatarsal head shapes, while all WBCT shape classifications were round. Conclusion: Unidimensional HV measurements were similar between WBCT and CR, while more three-dimensional findings were not. CR may be used to assess the axial aspects of HV, but multidimensional aspects of the deformity may not be accurately assessed with plain radiographs. Level of Evidence III; Therapeutic Studies; Retrospective Case-Control Study.

Complications of first tarsometatarsal joint arthrodesis

Objective: First tarsometatarsal joint (TMTJ) arthrodesis, also known as Lapidus, is a surgical procedure used to treat severe hallux valgus, associated hypermobility of the first ray, and/or osteoarthritis of the first TMTJ. Despite the high satisfaction rate and high corrective power, this technique is not without complications. This study aimed to report the complications of first TMTJ arthrodesis. Methods: This is a case series of 16 patients treated with first TMTJ arthrodesis. Patients were evaluated based on foot radiographs, clinical alignment of the hallux, and signs and symptoms. Results: Eight patients had either major or minor complications. Three patients had recurrent deformity (1 with associated nonunion), 2 had delayed union, 2 had hardware loosening (1 with associated nonunion), and 1 had wound dehiscence. Conclusion: First TMTJ arthrodesis requires greater care in choosing the surgical technique for the treatment of hallux valgus. In addition, some points should be considered to minimize complications as much as possible. We believe that data are still scarce to provide a concrete basis. Level of Evidence IV; Therapeutic Studies; Case Series.

One versus two adjacent interdigital neuroma excision: a patient outcome study

Objective: We aimed to evaluate patient satisfaction after surgery for both single and two adjacent neuromas. Methods: We reviewed the data of patients treated operatively for interdigital neuromas between 2003 and 2016. We interviewed them and administered the Self-Reported Foot and Ankle Score questionnaire. Patient scores were then analyzed categorically, and variation between groups was assessed. Results: Sixty-two patients were available for review. Thirty-one patients had a single interdigital neuroma excised and 31 had two adjacente interdigital neuromas excised. Twenty-eight of the 31 (90%) patients with a single neuroma had good or excellent results while 23 (74.2%) of those with adjacent neuromas had similar outcomes. One patient with a single neuroma had a poor result while four patients with adjacent neuromas had poor results. The mean score was 41 (excellent) for patients with a single interdigital neuroma and 37 (good) for those with adjacent neuromas (p=0.473). The majority of patients in both groups would undergo surgery again. Conclusion: We found no statistically significant difference in outcomes of patients who undergo surgery for either single or two adjacent interdigital neuromas. General patient satisfaction is good and/or excellent post excision. Level of Evidence II; Prognostic Studies; Retrospective Study.

Access to the talar dome through the medial posterolateral approach: an anatomical study.

Background: The osteochondral grafting has become a popular procedure for treating challenging talar dome lesions. However, the vast majority are treated through medial malleolus osteotomy. The aim of this study was to determine the posteromedial area of the talus that can be reached without malleolar osteotomy through the posteromedial approach. Study Design: Descriptive laboratory study. Evidence Level 4 Methods: Fifteen human cadaveric ankles were dissected in a standard fashion to expose the posteromedial talar dome. Seven approaches were used on the cadaver's left limb (46.7%). We did not observe any significant difference between the evaluated sides (chi-square test, p = 0.715). Results: On average, 2,09 cm2 (range, 1,72-2,69) of the posteromedial talus dome or 15,27 % (range 12-20) of total talus dome can be accessed without osteotomy. Conclusion: If the osteochondral lesion is within the area accessible through PM approach (mean 2 cm2), as seen on magnetic resonance imaging, it is possible that it can be treated without a medial malleolus osteotomy. Keywords: talus; osteochondral lesions; osteotomy; arthrotomy; surgery

Tendoscopic treatment of acute posterior tibial tendon dysfunction: case report

We present a case of a rheumatoid patient presenting with acute signs of posterior tibial tendon dysfunction (PTTD). Magnetic resonance imaging (MRI) results were inconclusive regarding the grade of posterior tibial tendon (PTT) tear. We performed posterior tibial tendoscopy, releasing all tendon adherences, and accomplished complete synovectomy. By the end of the procedure, we observed PTT integrity, normal excursion, and mild tendinosis. At 24-month follow-up, the Visual Analog Scale for pain (VAS-Pain) decreased from 9 (preoperatively) to 1. The Foot and Ankle Outcome Score (FAOS) increased from 16% (preoperatively) to 94%. Clinically, the patient had a symmetric bilateral heel rise test and no pain over the course of the PTT. A standard radiographic assessment demonstrated a normal foot arch and hindfoot alignment. This report illustrates how posterior tibial tendoscopy can simultaneously provide accurate diagnosis and surgically address acute PTTD on a rheumatoid patient, relieving symptoms and improving midterm clinical scores. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Concept, etiology, and pathomechanics of hallux rigidus

There is a continuous anatomical, functional and pathomechanical roadmap from functional hallux limitus to hallux rigidus. Although many etiologies for hallux rigidus have been studied it is very probable that it has a primary origin with less-than-ideal movement when we are born. Upon a restricted range of motion, symptoms may arise depending on the amount of work and how compensatory mechanisms work around the first metatarsophalangeal joint. Changes occurring at the joint that allow the transition from a sliding movement mechanism (physiological) to a rolling mechanism (pathological) may trigger anatomical and functional changes resulting in pain and dysfunction. Any surgical technique that is able to restore the sliding mechanism to the first metatarsophalangeal joint will have a positive impact on pain and function in a patient with a symptomatic functional hallux limitus/rigidus. Level of Evidence V; Therapeutic Study; Expert opinion.